River City Nursing and Rehab Center

In the surveyor’s words

From the most serious findings on record at River City Nursing and Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Feb 26, 2026

  Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to label and date mark an open beverage found in the 400 hallways nourishment room. Additionally observed were open bundles of bread in the cook area storage bin. Food handling and sanitation are important in health care settings serving nursing home residents. […]

• No harm, potential for more than minimal, patternF761Apr 14, 2022

  Based on observations, staff interview, and facility policy review, the facility failed to ensure safe and secure storage (including limited access and mechanisms to minimize loss or diversion) of all medications, with the potential of affecting all residents, related to staff not ensuring one (St. [NAME] nursing unit (rooms 300/400) of two treatment carts containing medications was locked when not in use and unattended. The findings include: On 4/10/22 at 12:10 p.m., an observation was made of an unlocked and unattended treatment cart on the St. [NAME] nursing unit (rooms 300/400). The same cart was observed unlocked and unattended at 1:53 p.m. The second drawer was opened, and multiple bags of medications with resident labels were observed. There was no staff observed in the area. […]

• No harm, potential for more than minimal, patternF725Jun 3, 2021

  Based on resident and staff interviews and a review of resident and facility records, the facility failed to maintain sufficient nursing staff to provide services and assistance in order to maintain the highest practicable well-being for three (Resident #2, #4 and #5) of four residents interviewed, and for one (Residents #2) of 3 residents reviewed for grievances, from a total of 6 residents in the sample. This had the potential to negatively impact all 66 residents in the facility at the time of the survey. The findings include: 1. An interview was conducted with Resident #2 on 06/03/21 at 11:15 AM. She stated the call light response times were long and took up to 40 minutes for staff to answer. This has, on occasion, resulted in her going to the bathroom on herself. […]

• No harm, potential for more than minimal, isolatedF656Feb 26, 2026

  Based on observations, record reviews and interviews, the facility failed to implement interventions identified in the comprehensive care plan for two (Residents #31 and #3) of 32 residents in the total survey sample. Resident #31 had no floor mat at bedside as per the physician's order and her care plan. Resident #3 had no pillow supporting her left elbow as per the physician's order and her care plan. Failing to follow these residents' care plans could result in falls with injuries, worsening of pressure areas, increased pain, and overall functional decline. The findings include:1.A review of Resident #31's medical record revealed that she was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, isolatedF550Apr 25, 2024

  Based on observations and record review, the facility failed to ensure dignity while dining for two (Residents #94 and 54) of two residents reviewed for dignity. The findings include: 1. On 04/24/24 at 8:18 AM, an observation was made of Resident #94 during her breakfast meal. She was lying in bed with her plate uncovered and the plate cloche cover lying on her bed. She was unable to eat her meal without staff assistance. Further observation revealed Certified Nursing Assistant (CNA) D entering the resident's room at 8:43 AM to assist her with eating. CNA D was observed standing over Resident #94 while assisting her with her meal. […]